GROSS ANATOMY

JULY 20, 2011

1.5 (2)
DR. MALIJAN

MUSCLES OF THE BACK

y y y y

THE MUSCLES OF THE BACK Serratus Posterior Superior Serratus Posterior Inferior Erector Spinae / Sacrospinalis Segmental muscles of the back EXTRINSIC MUSCLES

The Serratus Posterior Muscles (Superior and Inferior) y Serratus posterior superior is deep to rhomboid muscles y Serratus posterior inferior is deep to latissimus dorsi y Both serratus posterior muscles are attached to vertebral column and associated structures medially, and either descend (the fibers of serratus posterior superior) or ascend (the fibers of serratus posterior inferior) to attach to the ribs. INTRINSIC MUSCLES DEEP MUSCLES - Postvertebral muscles belonging to vertebral column - The postural tone of deep muscles is major factor responsible for maintenance of the normal curves of the vertebral column - extend from the sacrum to the skull

SUPERFICIAL MUSCLES Connected with the shoulder girdle. immediately deep to the skin and superficial fascia attach superior part of appendicular skeleton (clavicle, scapula, humerus) to axial skeleton (skull, ribs, vertebral column) Primarily involved w/ movements of upper appendicular skeleton; referred to as the appendicular group INTERMEDIATE MUSCLES

- involved with movements of thoracic cage - consist of 2 thin muscular sheets in superior & inferior regions of
back, immediately deep to the muscles in the superficial group

- Fibers from these two serratus posterior muscles (serratus

posterior superior & serratus posterior inferior) pass obliquely outward from vertebral column to attach to the ribs - referred to as the respiratory group

Extrinsic Intermediate Muscles of the Back

Gener, Anne, Tinelle, Ryzee, Em, Jan

Intermediate Muscles (Intrinsic Deep Muscles) Erector spinae (Sacrospinalis) large musculotendinous mass which differs in size and composition at different vertebral levels consists of fascicles that assume systematic attachments to homologous parts of the skull, the cervical, thoracic, and lumbar vertebrae, the sacrum, and the ilium individual muscles are defined by the attachments of their fascicles and the regions that they span.

Three erector spinae muscles: (with three regional parts each):

Iliocostalis Iliocostalis cervicis Iliocostalis thoracis Iliocostalis lumborum Longissimus capitis Longissimus cervicis Longissimus thoracis Spinalis thoracis Spinalis cervicis Spinalis capitis

Longissimus

Spinalis

Deep Muscles (Intrinsic Deep Muscles) Segmentals (Spinotransverse group) - consists of muscles where the fascicles span between a spinous process & transverse elements of vertebrae at various levels below - grouped according to length of fascicles & region that they cover Longest NERVE SUPPLY: Dorsal ramus of the spinal nerves Regions of the segmental muscles:
Rotatores Multifidus Semispinalis Interspinalis Intertransversarius Levatores costarum Rotatores thoracis Rotatores cervicis Rotatores capitis Multifidus Semispinalis cervicis Semispinalis thoracis Semispinalis capitis

Erector Spinae Muscle groups Origin, Insertion, Actions: Superficial ORIGIN: From iliac crest, sacrum, sacroiliac Erector spinae ligaments, inferior lumbar spinous 1. iliocostalis processes 2. longissimus 3. spinalis INSERTION: Iliocostalis: angles of the ribs Longissimus: transverse process of thoracic & cervical vertebrae, mastoid process of temporal bone Spinalis: spinous process of the thoracic vertebrae ACTIONS: - Extends the head and the vertebral column - Rotates the head to same side (longissimus) - Releases to allow flexion to be slow and controlled

Rotatores (Thoracic region)

Gener, Anne, Tinelle, Ryzee, Em, Jan

Multifundus. A. cervicothoracic B. Lumbosacral Origin, Insertion, Actions:

Segmental Muscles Action - Extends cervical & thoracic regions of vertebral region - Rotates these regions towards the opposite side - Extends the head - Unilaterally- flexes trunk laterally; rotates it to opposite side - Bilaterally extends trunk & stabilizes vertebral col. Rotate superior vertebrae to the opposite side Helps extend vertebral column Lateral flexion of superior vertebra Nerve Supply

The Triangle of Petit a.k.a. Lumbar Triangle where pus may emerge from the abdominal wall [*sabi ni Ma am did pa raw siya nakakaencounter ng case na may pus sa triangle na ito, baka daw super effective ng antibiotics] y Boundaries: o Latissimus dorsi o Posterior border of external oblique muscle of abdomen o Iliac crest

Semispinalis

Multifidus

Dorsal rami of cervical spinal nerves

Rotatores Interspinalis Intertransversarius Levatores costarum

Raises ribs during inspiration

ventral rami of cervical nerves -some dorsal rami of cervical nerves Dorsal rami of cervical region (lateral division)

Content of the Vertebral Canal I. Meninges and Spaces II. External Features of the Spinal Cord and Its Blood Vessels III. Cerebrospinal Fluid MENINGES AND SPACES

Meninges y Dura mater y Arachnoid mater y Pia mater Dura Mater Most external Dense, strong and fibrous Encloses spinal cord up to the cauda equina Continuous with dura of brain through foramen magnum Ends on filum terminale (lower border of S2) Continuous with connective tissue surrounding each spinal nerve (epineurium) at the intervertebral foramen - Lies loosely in vertebral canal and is separated from walls of canal by the Extradural Space - Inner surface is separated from Arachnoid mater by potential Subdural Space -

Muscular Triangles of the Back The Triangle of Auscultation a.k.a Auscultatory Triangle The site where breath sounds may be most easily heard with a stethoscope Boundaries: o Trapezius o Medial Border of the Scapula o Latissimus Dorsi

Gener, Anne, Tinelle, Ryzee, Em, Jan

Arachnoid Mater - Delicate, impermeable avascular membrane - Continuous with arachnoid membrane of brain (through foramen magnum) - Ends at filum terminale (lower border of S2) - Continued along the spinal nerve roots, forming extensions - Separated from the Pia mater by the Subarachnoid Space (filled with CSF) Pia Mater Vascular membrane Continuous with the pia mater of the brain (through the foramen magnum) Fuses with the filum terminale Thickened on either side of the nerve roots to form the ligamentum denticulatum Extends along each nerve root and becomes continuous with the connective tissue surrounding each spinal nerve

o the spinal cord tapers off into the conus medullaris, from the apex of which a prolongation of the pia mater, filum terminale descends to be attached to the back of the coccyx
y in the midline: anterior median fissure deep longitudinal fissure anterior posterior median sulcus shallow furrow posterior

THE SPINAL CORD - cylindrical, grayish white structure - From foramen magnum continuous with the medulla oblongata of the brain - terminates at the level of:  L1 adults  L2 children

o cervical o lumbar

Fusiform enlargements gives origin to the brachial plexus C4 to T1 in the lower thoracic and lumbar regions; gives origin to the lumbosacral plexus T11 TO L1

y Inferiorly:

Roots of the Spinal Nerves Spinal nerves - 31 pairs by anterior (motor) roots & posterior (sensory) roots - mixture of motor and sensory fibers. - formed by spinal nerve roots which pass laterally from each spinal cord segment to the level of their respective intervertebral foramina - Each root is attached to the cord by series of rootlets, which extend whole length of corresponding segment of cord - Each posterior nerve root possesses a posterior root ganglion, the cells of which give rise to peripheral and central nerve fibers  Because of the disproportionate growth in length of the vertebral column during development compared to that of the spinal cord, the length of the roots increases progressively from above downward In the upper cervical region the spinal nerve roots are short and run almost horizontally, but the roots of the lumbar and sacral nerves below the level of the termination of the cord (lower border of the first lumbar vertebra in the adult) form a vertical leash of nerves around the filum terminale. The lower nerve roots together are called the cauda equina

Gener, Anne, Tinelle, Ryzee, Em, Jan

Segmental branches of the intercostal and lumbar arteries

y Venous Drainage 3 anterior spinal sinuses or veins 3 posterior spinal sinuses or veins *The vein

After emergence from the intervertebral foramen, each spinal nerve immediately divides into a large anterior ramus and a smaller posterior ramus, which contain both motor and sensory fibers.

s of spinal cord drain into internal vertebral venous plexus. Meninges of the Spinal Cord Blood Supply of the Spinal Cord 2 Posterior Spinal arteries - arise either directly or indirectly from vertebral arteries - run down the side of spinal cord, close to attachments of posterior spinal nerve roots Anterior Spinal artery arise from the vertebral arteries, unite to form a single artery, which runs down within the anterior median fissure. Derived from: o Vertebral arteries o Deep cervical arteries o Intercostal arteries o Lumbar arteries - Reinforced by the Radicular Arteries enter the vertebral canal through intervertebral foramina Dura Mater most external membrane dense, strong, fibrous sheet encloses the spinal cord and cauda equine continuous above through foramen magnum with meningeal layer of dura covering brain - Inferiorly: ends on the filum terminale at the level of the lower border of the second sacral vertebra - dural sheath lies loosely in the vertebral canal separated from walls of canal by extradural space (epidural space) Extradural space (epidural space) - contains loose areolar tissue & internal vertebral venous plexus - extends along each nerve root and becomes continuous with connective tissue surrounding each spinal nerve (epineurium) at the intervertebral foramen. - inner surface : separated from arachnoid mater by potential subdural space Subdural space - Separates dura and arachnoid - contains a thin film of tissue fluid Arachnoid Mater - delicate impermeable membrane covering the spinal cord and lying between the pia mater internally and the dura mater externally - continuous above through foramen magnum with arachnoid covering brain - Inferiorly: ends on the filum terminale at the level of the lower border of second sacral vertebra (S2) - Between the levels of conus medullaris and lower end of the subarachnoid space lie the nerve roots of the cauda equina bathed in cerebrospinal fluid - continued along spinal nerve roots, forming small lateral extensions of the subarachnoid space. Subarachnoid space wide space separating arachnoid and pia mater filled with CSF

Gener, Anne, Tinelle, Ryzee, Em, Jan

Pia Mater vascular membrane that closely covers the spinal cord continuous above through the foramen magnum with pia covering brain below it fuses with the filum terminale. thickened on either side between the nerve roots to form the ligamentum denticulatum Passes laterally to be attached to dura It is by this means that the spinal cord is suspended in the middle of the dural sheath. extends along each nerve root and becomes continuous with the connective tissue surrounding each spinal nerve

For clinical diagnosis Introduce drugs Remove excess spinal fluid (headache)

Specific Spaces Where it is Done The patient lies on his side with his vertebrae well flexed. This widens the space between the adjoining laminae. The level of the fourth lumbar spine is determined by drawing an imaginary line joining the highest points of the iliac crest. Structures Pierced By the Spinal Needle The lumbar puncture needle is passed into the vertebral canal, above or below the fourth lumbar spine.

CEREBROSPINAL FLUID Clear, colorless fluid Formed by the choroid plexus (lateral, 3rd and 4th ventricles of the brain)

CSF enters the blood via the arachnoid villi into the dural sinus (superior sagittal sinuses).

Lumbar Tap Definition A procedure to withdraw cerebrospinal fluid for examination

STRUCTURES: 1. Skin 2. Superficial fascia 3. Supraspinous ligament 4. Interspinous ligament 5. Ligamentum flavum 6. Areolar tissue (containing the internal vertebral venous plexus in the epidural space) 7. Dura matter 8. Arachnoid matter 9. Subarachnoid space needle introduced into the subarachnoid space in this region usually pushes the nerve roots to one side without causing damage Depth to which the needle will have to pass varies from 1 in. (2.5 cm) or less in a child to as much as 4 in. (10 cm) in obese adults As stylet is withdrawn, a few drops of blood commonly escape. indicates that the point of the needle is situated in one of the veins of the internal vertebral plexus and has not yet reached the subarachnoid space. If the entering needle should stimulate one of the nerve roots of the cauda equina, the patient will experience a fleeting discomfort in one of the dermatomes, or a muscle will twitch, depending on whether a sensory or a motor root was impaled. If the needle is pushed too far anteriorly, it may hit the body of the third or fourth lumbar vertebra. In the recumbent position, the normal CSF pressure is about 60 to 150 mm H2O.

Gener, Anne, Tinelle, Ryzee, Em, Jan

Tables to memorize: (Copy paste from Dr. Malijan s powerpoint)

Muscle Serratus Posterior Superior Serratus Posterior Inferior

Origin Lower cervical and thoracic spines Upper Lumbar and Lower Thoracic Spines

Insertion Upper ribs

Nerve Supply Intercostal nerves

Action Raises the ribs and therefore inspiratory muscles Depresses ribs and therefore expiratory muscles

Lower ribs

Intercostal nerves

Superficial ERECTOR SPINAE 1. iliocostalis 2. longissimus 3. spinalis

Longest NERVE SUPPLY:

ORIGIN: From the iliac crest, sacrum, sacroiliac ligaments, inferior lumbar spinous processes INSERTION: Iliocostalis: angles of the ribs Longissimus: transverse process of the thoracic and cervical vertebrae, mastoid process of the temporal bone Spinalis: spinous process of the thoracic vertebrae ACTIONS: Extends the head and the vertebral column Rotates the head to same side (longissimus) Releases to allow flexion to be slow and controlled

Dorsal ramus of the spinal nerves

MUSCLE

NERVE SUPPLY

ACTION Extends the cervical and the thoracic regions of the vertebral region

Semispinalis

Rotates these regions towards the opposite side Extends the head Dorsal rami of the cervical spinal nerves Unilaterally- flexes the trunk laterally and rotates it to the opposite side Bilaterally extends the trunk and stabilizes the vertebral column

Multifidus

Rotatores

Rotate the superior vertebrae to the opposite side

Interspinalis Ventral rami of the cervical nerves Some dorsal rami of the cervical nerves Dorsal rami of the cervical region (lateral division)

Helps extend the vertebral column

Intertransversarius

Lateral flexion of the superior vertebra

Levatores costarum

Raises the ribs during inspiration

Gener, Anne, Tinelle, Ryzee, Em, Jan